PACU Handover Timeout - University of Michigan

PACU Handover Timeout

Enhancing the current process

Go-Live at UH: September 5th

Outline

? Current State ? Enhancements ? Expectations ? ASPIRE Metric ? PACU Handover Timeout Video ? Definition of PACU RN Brief Assessment ? Questions

Why is the PACU Handover Timeout important?

Information loss can occur during all phases of care.

During a handoff, information is at risk of degradation and miscommunication.

The transfer of care (handover) from the operating room to the postoperative anesthesia care unit (PACU) is an especially susceptible time. Information loss can lead to an increase in medication errors, sentinel events, and poor patient outcomes.

Submitted Patient Safety Report Forms

? "Pt sat in PACU w/o a service or orders to treat pt from 1500-0415 and with no contact from service from approx. 2300 until 0715 despite three pages to resident.

? Pt went to floor 13 hours after coming out of OR still w/o service orders. "

? "Though pt had orders for pain control pt did not have floor orders for over 1.5hrs which created a delay in care"

Submitted Patient Safety Report Forms

? "provider consistently gives a rushed, disrespectful, incomplete report. Leaves you

? "saw the contact precaution flagged for

feeling like you are a bother, insignificant and ridiculous for having expectations of

ESBL which nobody has mentioned on bedside

communication. They will tell you "ask the C3 for orders, I

report."

gotta go". This delays the patient

from getting the necessary timely

care we could be providing"

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